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Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 1 Ambulation (short term).
Figuras y tablas -
Analysis 1.1

Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 1 Ambulation (short term).

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Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 2 Reduction in analgesic use.
Figuras y tablas -
Analysis 1.2

Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 2 Reduction in analgesic use.

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Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 3 Urinary continence (short term).
Figuras y tablas -
Analysis 1.3

Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 3 Urinary continence (short term).

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Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 4 Gastrointestinal adverse effects.
Figuras y tablas -
Analysis 1.4

Comparison 1 Radiotherapy 8 fractions versus 2 fractions, Outcome 4 Gastrointestinal adverse effects.

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Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 1 Ambulation (short term).
Figuras y tablas -
Analysis 2.1

Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 1 Ambulation (short term).

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Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 2 Ambulation (intermediate term).
Figuras y tablas -
Analysis 2.2

Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 2 Ambulation (intermediate term).

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Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 3 Survival.
Figuras y tablas -
Analysis 2.3

Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 3 Survival.

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Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 4 Reduction in analgesic use.
Figuras y tablas -
Analysis 2.4

Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 4 Reduction in analgesic use.

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Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 5 Urinary continence (short term).
Figuras y tablas -
Analysis 2.5

Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 5 Urinary continence (short term).

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Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 6 Urinary continence (intermediate term).
Figuras y tablas -
Analysis 2.6

Comparison 2 Laminectomy plus radiotherapy versus radiotherapy alone, Outcome 6 Urinary continence (intermediate term).

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Comparison 3 Decompressive surgery plus radiotherapy versus radiotherapy alone, Outcome 1 Ambulation (short term).
Figuras y tablas -
Analysis 3.1

Comparison 3 Decompressive surgery plus radiotherapy versus radiotherapy alone, Outcome 1 Ambulation (short term).

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Comparison 3 Decompressive surgery plus radiotherapy versus radiotherapy alone, Outcome 2 Survival (short term).
Figuras y tablas -
Analysis 3.2

Comparison 3 Decompressive surgery plus radiotherapy versus radiotherapy alone, Outcome 2 Survival (short term).

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Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 1 Overall ambulation (short term).
Figuras y tablas -
Analysis 4.1

Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 1 Overall ambulation (short term).

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Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 2 Participants maintaining or regaining ambulation (short term).
Figuras y tablas -
Analysis 4.2

Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 2 Participants maintaining or regaining ambulation (short term).

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Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 3 Survival (long term).
Figuras y tablas -
Analysis 4.3

Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 3 Survival (long term).

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Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 4 Pain reduction.
Figuras y tablas -
Analysis 4.4

Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 4 Pain reduction.

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Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 5 Urinary continence (short term).
Figuras y tablas -
Analysis 4.5

Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 5 Urinary continence (short term).

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Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 6 Serious drug related adverse effects.
Figuras y tablas -
Analysis 4.6

Comparison 4 High dose versus no or moderate dose corticosteroids, Outcome 6 Serious drug related adverse effects.

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Table 1. Detailed results

Parameters

Results

Different radiotherapy schedules (Eight versus two fractions)

Overall ambulatory rates (short term)

95/134 (71%) versus 97/142 (68%) RR 1.02; (95% CI 0.90 to 1.15) (n = 276).

Pretreatment ambulant participants maintaining ambulation (short term)

83/91 (91%) versus 83/93 (89%) RR 1.02; (95% CI 0.93 to 1.12) (n = 184).

Pretreatment non‐ambulant participants regaining ambulation (short term)

12/43 (28%) versus 14/49 (29%) RR 0.98; (95% CI 0.51 to 1.88) (n = 92)

Median duration of ambulation

3.5 months in both arms (excluding 17 early deaths)

Survival

Four months in both arms (excluding 17 early deaths), five months in pretreatment ambulant participants and three months in pretreatment non‐ambulant participants.

Pain relief (short term)

61/126 (48%) versus 52/136 (38%) RR 1.24; (95% CI 0.94 to 1.64) (n = 262)

Urinary continence (short term)

118/134 (89%) versus 128/142 (90%) RR 0.97; (95% CI 0.93 to 1.02) (n = 275)

Participants maintaining urinary continence (short term)

116/120 (97%) versus 126/126 (100%) RR 0.97; (95% CI 0.93 to 1.00) (n = 246)

Participants regaining urinary continence (short term)

2/13 (15%) versus 2/16 (13%) RR 1.23; (95% CI 0.20 to 7.58) (n = 29)

Adverse effects (early)

Grade three acute gastrointestinal mucositis attributable to radiation ‐ 5/134 (4%) versus 3/142 (2%) RR 1.77; (95% CI 0.43 to 7.25) 6/276 participants had Grade three vomiting; the incidence was similar in both the arms. Grade three nausea was present in 5/276 participants (n = 276).

Adverse effects (late)

No documented late radiation myelopathy or serious adverse effects

Outcomes not reported

Survival rates, quality of life, participant and caregiver satisfaction.

Laminectomy plus radiotherapy versus radiotherapy alone

Overall ambulatory rates (short term)

7 /16 (44%) versus 7/13 (54%) RR 1.20; (95% CI 0.59 to 2.43) (n = 29)

Pretreatment ambulant participants maintaining ambulation (short term)

3/6 (50%) versus 5/5 (100%) RR 1.83; (95% CI 0.84 to 4.00) (n = 11)

Pretreatment non‐ambulant participants regaining ambulation (short term)

4/10 (40%) versus 2/8 (25%) RR 0.63; (95% CI 0.15 to 2.59) (n = 18)

Overall ambulatory rates (intermediate term)

6/9 (67%) versus 5/6 (83%) RR 1.25; (95% CI 0.70 to 2.24) (n = 15)

Survival (short term)

16/16 (100%) versus 10/13 (76%) RR 0.77; (95% CI 0.56 to 1.06) (n = 29)

Survival (Intermediate term)

9/16 (56%) versus 6/13 (46%) RR 0.82; (95% CI 0.40 to 1.70) (n = 29)

Pain relief

8/14 (57%) versus 6/12 (50%) RR 0.88; (95% CI 0.42 to 1.81) (n = 26)

Overall urinary continence (short term)

7/16 (44%) versus 7/13 (54%) 95% CI RR 0.94; (95% CI 0.50 to 1.77) (n = 29)

Proportion of participants maintaining urinary continence (short term)

6/8 (75%) versus 6/10 (60%) RR 0.80; (95% CI 0.42 to 1.52) (n = 18)

Proportion of participants regaining urinary continence (short term)

1/8 (13%) versus 1/3 (33%) RR 2.67; (95% CI 0.23 to 30.40) (n = 11)

Overall urinary continence (intermediate term)

6/9 (67%) versus 6/6 (100%) RR 1.43; (95% CI 0.87 to 2.35) (n = 15)

Adverse effects

There were no surgery or radiotherapy related complications

Outcomes not reported

Quality of life, participant and caregiver satisfaction.

Direct decompressive surgery with radiotherapy versus radiotherapy

Overall ambulatory rates (short term)

29/51 (57%) versus 42/50 (84%), RR 0.67; (95% CI 0.53 to 0.86) (n = 101), NNTB 3.70 (95% CI 2.38 to 7.69)

Proportion of pretreatment ambulant participants maintaining ambulation (short term)

26/35 (74%) versus 32/34 (94%) RR 0.79; (95% CI 0.64 to 0.98) (n = 69), NNTB 5.00 (95% CI 2.78 to 33.33)

Proportion of pretreatment non‐ambulant participants regaining ambulation (short term)

3/16 (19%) versus 10/16 (63%) RR 0.30; (95% CI 0.10 to 0.89) (n = 32), NNTB 2.27 (95% CI 1.35 to 7.69)

Median duration of ambulation

The median duration of ambulation was 13 days versus 122 days, (those maintaining ambulation 54 days versus 153 days and regaining ambulation was 0 versus 59 days)

Survival (short term)

44/51 (86%) versus 47/50 (94%) RR 0.92; (95% CI 0.81 to 1.05) (n = 101)

Median survival

100 days versus 126 days

Outcomes not reported

Quality of life, participant and care giver satisfaction were not assessed. Participant rated pain relief , adverse effects and dichotomous data for analgesic reduction and urinary continence

High dose corticosteroids versus no or moderate dose corticosteroids

Overall ambulatory rates (short term)

RR 0.91; (95% CI 0.68 to 1.23) (n = 105, three trials)

Proportion of pretreatment ambulant participants maintaining ambulation (short term)

17/17 (100%) versus 17/19 (90%) RR 0.90; (95% CI 0.75 to 1.08) (n = 36, one trial)

Proportion of pretreatment non‐ambulant participants regaining ambulation (short term)

5/10 (50%) versus 2/11 (18%) RR 0.36; (95% CI 0.09 to 1.47) (n = 21, one trial)

Survival (long term)

5/10 (50%) versus 2/11 (18%) RR 0.36; (95% CI 0.09 to 1.47) (n = 21, one trial)

Pain relief

11/14 (79%) versus 10/11(91%) RR 1.16; (95% CI 0.83 to 1.61) (n = 25, one trial)

Urinary continence

12/19 (63%) versus 8/15 (53%) RR 0.84; (95% CI 0.47 to 1.52) (n = 34, one trial)

Adverse effects

High dose corticosteroids versus no or moderate dose corticosteroids RR 0.12; (95% CI 0.02 to 0.97) (n = 77, two trials) High dose versus no corticosteroids RR 0.10; (95% CI 0.01 to 1.78) (n = 57, one trial) High dose versus moderate dose corticosteroids RR 0.17; (95% CI 0.01 to 3.08) (n = 20, one trial)

Outcomes not reported

Quality of life, participant rated and care giver satisfaction. Intermediate term outcomes from Sorensen 1994 could not be calculated as survival rates were not available.

Figuras y tablas -
Table 1. Detailed results
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Comparison 1. Radiotherapy 8 fractions versus 2 fractions

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Ambulation (short term) Show forest plot

1

276

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.90, 1.15]

1.1 Pretreatment ambulant subgroup ‐ maintaining ambulation

1

184

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.93, 1.12]

1.2 Pretreatment non‐ambulant subgroup ‐ regaining ambulation

1

92

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.51, 1.88]

2 Reduction in analgesic use Show forest plot

1

262

Risk Ratio (M‐H, Fixed, 95% CI)

1.27 [0.96, 1.67]

3 Urinary continence (short term) Show forest plot

1

275

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.93, 1.02]

3.1 Proportion maintaining urinary continence

1

246

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.93, 1.00]

3.2 Proportion regaining urinary continence

1

29

Risk Ratio (M‐H, Fixed, 95% CI)

1.23 [0.20, 7.58]

4 Gastrointestinal adverse effects Show forest plot

1

276

Risk Ratio (M‐H, Fixed, 95% CI)

1.77 [0.43, 7.25]
Figuras y tablas -
Comparison 1. Radiotherapy 8 fractions versus 2 fractions
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Comparison 2. Laminectomy plus radiotherapy versus radiotherapy alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Ambulation (short term) Show forest plot

1

29

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.59, 2.43]

1.1 Pretreatment ambulant subgroup ‐ maintaining ambulation

1

11

Risk Ratio (M‐H, Fixed, 95% CI)

1.83 [0.84, 4.00]

1.2 Pretreatment non‐ambulant subgroup ‐ regaining ambulation

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.15, 2.59]

2 Ambulation (intermediate term) Show forest plot

1

15

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [0.70, 2.24]

3 Survival Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Short term survival

1

29

Risk Ratio (M‐H, Fixed, 95% CI)

0.77 [0.56, 1.06]

3.2 Intermediate term survival

1

29

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.40, 1.70]

4 Reduction in analgesic use Show forest plot

1

26

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.42, 1.81]

5 Urinary continence (short term) Show forest plot

1

29

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.50, 1.77]

5.1 Proportion maintaining urinary continence

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

0.8 [0.42, 1.52]

5.2 Proportion regaining urinary continence

1

11

Risk Ratio (M‐H, Fixed, 95% CI)

2.67 [0.23, 30.40]

6 Urinary continence (intermediate term) Show forest plot

1

15

Risk Ratio (M‐H, Fixed, 95% CI)

1.43 [0.87, 2.35]
Figuras y tablas -
Comparison 2. Laminectomy plus radiotherapy versus radiotherapy alone
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Comparison 3. Decompressive surgery plus radiotherapy versus radiotherapy alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Ambulation (short term) Show forest plot

1

101

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.53, 0.86]

1.1 Pretreatment ambulant subgroup ‐ maintaining ambulation

1

69

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.64, 0.98]

1.2 Pretreatment non‐ambulant subgroup regaining ambulation

1

32

Risk Ratio (M‐H, Fixed, 95% CI)

0.3 [0.10, 0.89]

2 Survival (short term) Show forest plot

1

101

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.81, 1.05]
Figuras y tablas -
Comparison 3. Decompressive surgery plus radiotherapy versus radiotherapy alone
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Comparison 4. High dose versus no or moderate dose corticosteroids

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Overall ambulation (short term) Show forest plot

3

105

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.68, 1.23]

1.1 High dose versus no corticosteroids

1

57

Risk Ratio (M‐H, Fixed, 95% CI)

0.78 [0.56, 1.08]

1.2 High versus moderate corticosteroids

2

48

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.68, 2.12]

2 Participants maintaining or regaining ambulation (short term) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Pretreatment ambulant subgroup ‐ maintaining ambulation

1

36

Risk Ratio (M‐H, Fixed, 95% CI)

0.9 [0.75, 1.08]

2.2 Pretreatment non‐ambulant subgroup regaining ambulation

1

21

Risk Ratio (M‐H, Fixed, 95% CI)

0.36 [0.09, 1.47]

3 Survival (long term) Show forest plot

1

57

Risk Ratio (M‐H, Fixed, 95% CI)

0.9 [0.20, 4.09]

4 Pain reduction Show forest plot

1

25

Risk Ratio (M‐H, Fixed, 95% CI)

1.16 [0.83, 1.61]

5 Urinary continence (short term) Show forest plot

1

34

Risk Ratio (M‐H, Fixed, 95% CI)

0.84 [0.47, 1.52]

6 Serious drug related adverse effects Show forest plot

2

77

Risk Ratio (M‐H, Fixed, 95% CI)

0.12 [0.02, 0.97]

6.1 High dose versus no corticosteroids

1

57

Risk Ratio (M‐H, Fixed, 95% CI)

0.10 [0.01, 1.78]

6.2 High dose versus moderate dose corticosteroids

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.01, 3.08]
Figuras y tablas -
Comparison 4. High dose versus no or moderate dose corticosteroids
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